Case ReportRecurrent Oral Mucocele Management with Diode Laser

Amira Besbes ,1,2 Yamina Elelmi,1,3 Faten Khanfir,1,4 Raja Belgacem,3

and Hichem Ghedira1,3

1University of Monastir, Faculty of Dental Medicine, 5019 Monastir, Tunisia2University Dental Clinic, Oral Medicine and Oral Surgery Department, Medical and Molecular Parasitology andMycology Laboratory, LR12ES08, 5019 Monastir, Tunisia3University Dental Clinic, Pediatric Dentistry Department, Dento-Facial Biological and Clinical Approach Laboratory, LR12ES10,5019 Monastir, Tunisia4University Dental Clinic, Outpatient Department, Research Laboratory of Oral Health and Orofacial Rehabilitation,LR12ES11 Monastir 5000, Tunisia

Correspondence should be addressed to Amira Besbes; besbesemira@gmail.com

Received 17 July 2020; Revised 31 August 2020; Accepted 24 September 2020; Published 5 October 2020

Academic Editor: Giuseppe Alessandro Scardina

Copyright © 2020 Amira Besbes et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Mucocele is the most common minor salivary glands disease. Its management may present a challenge for dentalprofessionals. The aim of the present clinical case was to describe mucocele treatment with diode laser and its benefits. CaseReport. A case of lower lip mucocele in a 10-year-old female patient is reported. A conventional excision surgery was performed.Two months later, the patient reported discomfort and swelling at the same operative site. The lesion had recurred. Thus,mucocele was removed using a diode laser with wavelength of 980 nm, an initiated fiberoptic tip of 300μm, in continuousmode, and a power setting of 2Watts. The procedure was rapidly completed with no bleeding. The patient was followed-upafter 2 weeks and 6 months. The wound healed without complications: no postoperative discomfort or pain and no infection.There was no recurrence. Conclusion. Diode laser is an effective, easy, bloodless, and well-accepted procedure to treat mucocelein pediatric patients.

1. Introduction

Mucocele is a common oral lesion affecting minor salivaryglands. It develops by extravasation or retention of mucous[1–4].

According to the literature, mucoceles occur more fre-quently in the lower lip [5–9]. This can be explained by thesharp borders of children’ incisives biting lower lip, leadingto a trauma or repeated stimulation [5, 10, 11].

The other affected sites are the tongue, palate, cheek, andfloor of the mouth [9, 12]. Clinically, the lesion appears as apink or bluish fluctuant nodule that may vary in color andsize [5]. It may break off and resolve spontaneously [13, 14].

Many procedures were performed for mucocele remov-ing: conventional surgery which is the most recommendedmethod, electrosurgery, cryosurgery, micromarsupialization,

and marsupialization. Steroids injection was also reported [2,4, 8, 15, 16].

Many authors have described diode laser application formucosal lesions in the oral cavity as an alternative to theprecedent methods [17, 18].

Lasers offer many advantages such as ease of working,reducedhealing time, andhigh affinity formelatonin andhemo-globin. Soft tissues may be cut, excised, or vaporized [18, 19].

The objective of this paper was to describe the use ofdiode laser to treat a recurrent mucocele in a young patientand its advantages.

2. Case Report

A 10-year-old girl consulted the Pediatric Dentistry Depart-ment in Monastir University Dental Clinic, Tunisia. She

HindawiCase Reports in DentistryVolume 2020, Article ID 8855759, 5 pageshttps://doi.org/10.1155/2020/8855759

complained about recurrent mucocele which was surgicallyremoved in the last 2 months. The patient described discom-fort and swelling in the right part of the lower lip. The lesionwas increasing in size and symptoms appeared when bitingher lip. History and clinical examination revealed a recurrentmucocele: a small pink nodule measuring 5mm of diameterin the lower lip (Figure 1).

The treatment plan consisted on mucocele removal withlaser application. Informed consent was obtained from theparent’s patient. The procedure was conducted in accordancewith the Helsinki Declaration.

Diode laser (Doctor Smile Simpler, Lambda, Italy) wasused under local anesthesia (Medicaine 2% with adrenaline1/100.000®, Medis, Tunisia).

This laser device emits photons at a wavelength of980nm and operates in a continuous emission mode with asupplementary gated emission. This device has a maximumpower output of 8W, with a repetition rate that can attain25 kHz. The delivery system is a quartz fiber optic. For thisspecific case, a 300μm initiated tip was employed and thelaser was set according to the following parameters:

(i) Peak power: 2W

(ii) Emission mode: continuous wave

(iii) Average power: 2W

(iv) Length of treatment: 300 sec

(v) Tip-to-tissue distance: in contact

(vi) Speed of movement: 1mm/sec

(vii) Total energy delivered: 600 joules

All the practitioners and the patient wore laser eye pro-tectors. The tip was directed to the surface of the lip at thebase of the lesion at an angle of 10 to 15°. Movements wereperformed around the base, while the mucocele was grabbedby tweezers (Figure 2). The site was slowly and continuouslymopped by sterile wet gauze to avoid tissues overheating.Care was taken also to always control the tip. If uponinspection, any damage or collection of debris was observedduring treatment, the tip was cleaned with a sterile gauze.The mucocele was totally removed in 5 minutes. No bleed-ing was observed in the operative site and no sutures werenecessary (Figure 3). The patient was told not to bite her lipsand if healing was not complete by 4 weeks or any recur-rence appeared, she should return for further examinationand treatment. Histopathologic examination of removaltissue confirmed the diagnosis of mucocele. It showed aregular Malpighian epithelium, and a subepithelial connec-tive tissue occupied by a cystic cavity which was surroundedby a granulation tissue. The infiltrate was rich in macro-phages (Figure 4).

The child was followed after 2 weeks: a fibrin networkformed over the surface (Figure 5). The wound healed with-out complications: no postoperative discomfort or pain andno infection were noted. No recurrence was observed. Thesurface of the lip healed perfectly after 6 months of follow-up (Figure 6).

3. Discussion

Mucoceles are frequent benign lesions in young individuals[8]. In the present case, a mucocele on a young girl wastreated two times. At first time, a scalpel excision was done.After recurrence, we decided to use diode laser approach.

Etiologic factor of mucous cyst development in the lowerlip may be caused by chronic trauma arising out of feedingand biting habit that can initiate inflammatory or hemor-rhagic phenomena [20, 21]. Moreover, saliva secreted in theoral cavity by salivary glands through ducts. If these ductsare blocked or traumatized, the saliva is collected at the cutspot leading to swelling or a mucocele [2, 8, 9, 13, 22–24].

Surgical extirpation of mucoceles is the most commontreatment [15]. However, the method itself can traumatizetissues and cause recurrence [25].

In this case, clinical features and history indicate therecurrence of the lesion: same location, history of trauma,and rapid appearance. Besides, the patient had a habit ofbiting her lower lip by the borders of the anterior maxillaryteeth. The space between incisors and mechanical stimula-tion may be the cause of mucocele appearance and recur-rence [10]. Therefore, the patient was encouraged to stopher bad habit.

The important practical points to be considered leadingto a successful operation without recurrence are excisingthe cyst and the adjacent minor salivary glands and extend-ing the removed area to the muscle layer [12, 19].

In the present case, the surgery was completed in 5minutes. This characteristic is in accordance with otherauthors’ observations [12]. It was also bloodless and therewas no need for suture.

Laser diode treatment has proven a satisfying result whenused to treat oral soft tissues [19] especially for youngpatients [7].

Our findings showed that this latter has many advan-tages: good hemostasis during and after operation, procedurespeed which minimizes discomfort especially for childrenand lack of complications during or after application.

Laser diodes are used to manage oral soft tissues becausethey is highly absorbed by water and hemoglobin, melanin,and collagen chromophores and poorly absorbed by dentalhard tissues [21, 26, 27]. Laser provides cut and coagulationat the mean time so bleeding is significantly reduced or even

Figure 1: Clinical appearance of the mucocele in the lower lip.

2 Case Reports in Dentistry

absent. There is no need to suture the operating site [17, 27,28]. In addition, the site is immediately disinfected by thelaser [17]. This tool enhances wound healing withoutinfection or swelling because it has antibacterial and anti-inflammatory properties [21, 29]. These effects are mostlydesired in developing countries who have higher postopera-tive complications [20, 21].

Tunisia has an arid climate with humidity zones. Besides,the child came from a rural region where the control infec-tion measures may be unavailable. These conditions rise a

concern about the possibility of secondary infection occur-rence which prompt caution regarding contamination. Butin this case, the need for medication was eliminated. The girlwas confident and more cooperative when laser was used.Furthermore, she began to reduce her biting habit. Conse-quently, the healing was perfect without any scarring orinfection and the patient did not complain about anyunpleasant feeling.

Diode laser improve wound recovery. Cicatrization timeis shorter than after conventional surgery [21]. Six monthsof follow-up did not show any recurrence.

When done with care, this alternative may be moresuccessful and helpful with less recurrence, less postoperativediscomfort for pediatric patients.

Usually the diode lasers are associated with aluminum,gallium, and arsenic [21]. They have a wavelength between810 nm and 980nm [18]. Laser irradiation for oral soft tissueprocedures can be in continuous mode or pulsed mode [18].It can be used for ablation, incision, excision coagulation, andhemostasis [18, 21].

It makes sense to know that this type of laser produces arapid increase in the temperature of the target tissue [18].Thus, particular attention must be paid to the time of appli-cation and the working power in order to prevent adjacenttissues overheating and necrosis [21].

This clinical case agrees with previous reports substanti-ating that diode laser treatment may be a good therapeutic

Figure 2: Diode laser tip handled around the lesion.

Figure 3: Immediate aspect after mucocele removal: bloodlessoperative site, no suture was done.

Figure 4: Histopathologic findings showing a regular Malpighianepithelium and a subepithelial connective tissue occupied by acystic cavity which was surrounded by a granulation tissue(hematoxylin and eosin, original magnification, ×100).

Figure 5: After 2weeks of follow-up:fibrinnetwork recovered the site.

Figure 6: Perfect healing after 6 months of follow-up.

3Case Reports in Dentistry

alternative for oral lesions and particularly suitable forinfants. However, more studies are needed to comparelong-term efficacy of this device with other laser types.

4. Conclusion

Diode laser application is rapid, efficient, and safe. It is well-accepted by young patients because it is painless and has nopostoperative complications. The comfort provided by thistechnique spurs dental practitioners to use it in their routinework.

Data Availability

The data (figures) used to support the findings of this studyare included within the article.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

The authors would like to express their gratitude to Dr. BilelMaraoui for the demonstration and the explanation of thedevice operating instructions. The authors would also thankthe patient and her parent for their cooperation.

References

[1] M. M. S. Nico, J. H. Park, and S. V. Lourenço, “Mucocele inPediatric Patients: Analysis of 36 Children,” Pediatric Derma-tology, vol. 25, no. 3, pp. 308–311, 2008.

[2] J. Ata-Ali, C. Carrillo, C. Bonet, J. Balaguer, M. Penarrocha,and M. Penarrocha, “Oral mucocele: review of the literature,”Journal of Clinical and Experimental Dentistry, vol. 2, no. 1,pp. e18–e21, 2010.

[3] C. W. Wu, Y.-H. Kao, C.-M. Chen, H. J. Hsu, C.-M. Chen, andI.-Y. Huang, “Mucoceles of the oral cavity in pediatricpatients,” The Kaohsiung Journal of Medical Sciences, vol. 27,no. 7, pp. 276–279, 2011.

[4] M. OKA, E. NISHIOKA, R. MIYACHI, M. TERASHIMA, andC. NISHIGORI, “Case of superficial mucocele of the lower lip,”The Journal of Dermatology, vol. 34, no. 11, pp. 754–756, 2007.

[5] N. Singh, P. Chandra, and S. Agarwal, “Oral Mucocele: A CaseReport,” Journal of Dentofacial Sciences, vol. 3, no. 1, pp. 47–50, 2014.

[6] J. Mott and J. A. Morrison, “Salivary Mucocele,” in Blackwell’sFive-Minute Veterinary Consult Clinical Companion, pp. 164–171, John Wiley & Sons, Inc., Hoboken, NJ, USA, 2019.

[7] M. Chinta, A. J. Saisankar, C. Birra, and P. K. Kanumuri, “Suc-cessful management of recurrent mucocele by diode laser andthermoplasticised splint as an adjunctive therapy,” BMJ CaseReports, vol. 2016, p. bcr2016216354, 2016.

[8] L. Bodner, E. Manor, B.-Z. Joshua, and R. Shaco-Levy, “OralMucoceles in Children-Analysis of 56 New Cases,” PediatricDermatology, vol. 32, no. 5, pp. 647–650, 2015.

[9] M. Paglia, R. Crippa, F. Ferrante, and F. Angiero, “Mucocele ofthe minor salivary glands in an infant: treatment with diodelaser,” European Journal of Paediatric Dentistry, vol. 16,no. 2, pp. 139–142, 2015.

[10] A. Abe, K. Kurita, H. Hayashi, and M. Minagawa, “Multiplemucoceles of the lower lip: A case report,” Clinical CaseReports, vol. 7, no. 7, pp. 1388–1390, 2019.

[11] P. de CamargoMoraes, M. Bönecker, C. Furuse, L. A. Thomaz,R. G. Teixeira, and V. C. de Araújo, “Mucocele of the gland ofBlandin–Nuhn: histological and clinical findings,” ClinicalOral Investigations, vol. 13, no. 3, pp. 351–353, 2009.

[12] I.-Y. Huang, C.-M. Chen, Y.-H. Kao, and P. Worthington,“Treatment of Mucocele of the Lower Lip With Carbon Diox-ide Laser,” Journal of Oral and Maxillofacial Surgery, vol. 65,no. 5, pp. 855–858, 2007.

[13] S. Bagher, A. Sulimany, M. Kaplan, and C. Loo, “TreatingMucocele in Pediatric Patients Using a Diode Laser: ThreeCase Reports,” Dentistry Journal, vol. 6, no. 2, p. 13, 2018.

[14] I. Mínguez-Martinez, C. Bonet-Coloma, J. Ata-Ali-Mahmud,C. Carrillo-García, M. Peñarrocha-Diago, andM. Peñarrocha-Diago, “Clinical Characteristics, Treatment,and Evolution of 89 Mucoceles in Children,” Journal of OralandMaxillofacial Surgery, vol. 68, no. 10, pp. 2468–2471, 2010.

[15] P. Chaitanya, D. Praveen, and M. Reddy, “Mucocele on lowerlip: a case series,” Indian Dermatology Online Journal, vol. 8,no. 3, pp. 205–207, 2017.

[16] S. Twetman and S. Isaksson, “Cryosurgical treatment of muco-cele in children,” American Journal of Dentistry, vol. 3, no. 4,pp. 175-176, 1990.

[17] D. Ortega-Concepcion, J. A. Cano-Duran, J. F. Peña-Cardelles,V. M. Paredes-Rodriguez, J. Gonzalez-Serrano, and J. Lopez-Quiles, “The application of diode laser in the treatment of oralsoft tissues lesions. A literature review,” Journal of Clinical andExperimental Dentistry, vol. 9, no. 7, pp. e925–e928, 2017.

[18] E. Azma and N. Safavi, “Diode laser application in soft tissueoral surgery,” J Lasers Med Sci., vol. 4, no. 4, pp. 206–211, 2013.

[19] A. Ahad, S. Tandon, A. K. Lamba, F. Faraz, P. Anand, andA. Aleem, “Diode Laser Assisted Excision and Low Level LaserTherapy in the Management of Mucus Extravasation Cysts: ACase Series,” Journal of Lasers in Medical Sciences, vol. 8, no. 3,pp. 155–159, 2017.

[20] J. Kato and R. L. Wijeyeweera, “The Effect of CO2Laser Irradi-ation on Oral Soft Tissue Problems in Children in Sri Lanka,”Photomedicine and Laser Surgery, vol. 25, no. 4, pp. 264–268,2007.

[21] J. R. Boj, C. Poirier, M. Hernandez, E. Espasa, and A. Espanya,“Review: Laser soft tissue treatments for paediatric dentalpatients,” European Archives of Paediatric Dentistry, vol. 12,no. 2, pp. 100–105, 2011.

[22] I. S. Indiarti and D. Ariawan, “A case report of mucocele,”International Journal of Clinical Preventive Dentistry, vol. 9,no. 4, pp. 253–256, 2013.

[23] J. M. Aldrigui, P. E. d. Silva, F. C. A. Xavier, F. D. Nunes, S. K.Bussadori, and M. T. Wanderley, “Mucocele of the lower lip ina 1-year-old child,” Pediatric Dental Journal, vol. 20, no. 1,pp. 95–98, 2010.

[24] R. N. Bahadure, P. Fulzele, N. Thosar, G. Badole, and S. Baliga,“Conventional surgical treatment of oral mucocele: a series of23 cases,” European Journal of Paediatric Dentistry, vol. 13,no. 2, pp. 143–146, 2012.

[25] M. Marcushamer, D. L. King, and N. S. Ruano, “Cryosurgeryin the management of mucoceles in children,” Pediatric Den-tistry, vol. 19, no. 4, pp. 292-293, 1997.

[26] M. B. F. Amaral, J. M. S. de Ávila, M. H. G. Abreu, and R. A.Mesquita, “Diode laser surgery versus scalpel surgery in the

4 Case Reports in Dentistry

treatment of fibrous hyperplasia: a randomized clinical trial,”International Journal of Oral and Maxillofacial Surgery,vol. 44, no. 11, pp. 1383–1389, 2015.

[27] E. Mathur, M. Sareen, P. Dhaka, and P. Baghla, “Diode LaserExcision of Oral Benign Lesions,” Journal of lasers in medicalsciences, vol. 6, no. 3, pp. 129–132, 2015.

[28] M. C. Vitale, M. F. Sfondrini, G. A. Croci et al., “DiodeLaser-Assisted Surgical Therapy for Early Treatment of OralMucocele in a Newborn Patient: Case Report and Proce-dures Checklist,” Case Reports in Dentistry, vol. 2018, Arti-cle ID 3048429, 6 pages, 2018.

[29] B. Nazemisalman, M. Farsadeghi, and M. Sokhansanj, “Typesof Lasers and Their Applications in Pediatric Dentistry,” Jour-nal of lasers in medical sciences, vol. 6, no. 3, pp. 96–101, 2015.

5Case Reports in Dentistry